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Chronic Diarrhea Evaluation in the Elderly: IBS or Something Else?

  • Gastroenterology in Geriatric Patients (S Chokhavatia, Section Editor)
  • Published:
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Abstract

Purpose of Review

Chronic diarrhea is a common problem in all age groups but is a particularly challenging diagnostic problem in the elderly, since many different conditions need to be considered. The purpose of this review is to discuss the evaluation of chronic diarrhea in older individuals. It highlights those conditions that seem to occur with increased frequency in the elderly, discusses the diagnostic tests that are of greatest value in sorting out these problems, and presents an approach to evaluation that is both practical and affordable.

Recent Findings

There appears to be little value in distinguishing irritable bowel syndrome with diarrhea (IBS-D) from functional diarrhea in most patients, including older individuals. Both conditions need a thoughtful analysis of potential causes that may lead to more focused treatment. Older individuals may be more at risk of having certain structural disorders, and these need to be considered when constructing a differential diagnosis. In addition, elderly patients may have atypical presentations of specific disorders that require an increased index of suspicion. Diagnostic tests generally seem to perform well in older patients but have not been validated in this cohort of patients. Although the pretest probabilities of certain diseases are different in the elderly, the conventional algorithm for assessment of chronic diarrhea should lead to a diagnosis in most cases.

Summary

Better studies are needed to adequately quantitate the likelihood of different diagnoses and the operating characteristics of diagnostic tests in older patients with chronic diarrhea. Lacking that information, physicians can still do a good job of making a diagnosis in these patients by adopting a stepwise approach.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Singh P, Mitsuhashi S, Ballou S, Rangan V, Sommers T, Cheng V, et al. Demographic and dietary associations of chronic diarrhea in a representative sample of adults in the United States. Am J Gastroenterol. 2018;113(4):593–600.

    Article  Google Scholar 

  2. • Schiller LR, Pardi DS, Sellin JH. Chronic diarrhea: diagnosis and management. Clin Gastroenterol Hepatol. 2017;15(2):182–93. A series of issues that frame the evaluation and management of chronic diarrhea.

    Article  Google Scholar 

  3. •• Schiller LR. Evaluation of chronic diarrhea and irritable bowel syndrome with diarrhea in adults in the era of precision medicine. Am J Gastroenterol. 2018;113(5):660–9. Basic approach to evaluation of chronic diarrhea in adults.

    Article  Google Scholar 

  4. Steffer KJ, Santa Ana CA, Cole JA, Fordtran JS. The practical value of comprehensive stool analysis in detecting the cause of idiopathic chronic diarrhea. Gastroenterol Clin N Am. 2012;41(3):539–60.

    Article  Google Scholar 

  5. Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Grant Thompson W, et al. U. S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38(9):1569–80.

    Article  CAS  Google Scholar 

  6. Almario CV, Ballal ML, Chey WD, Nordstrom C, Khanna D, Spiegel BMR. Burden of gastrointestinal symptoms in the United States: results of a nationally representative survey of over 71,000 Americans. Am J Gastroenterol. 2018;113(11):1701–10.

    Article  Google Scholar 

  7. Talley NJ, O’Keefe EA, Zinsmeister AR, Melton LJ 3rd. Prevalence of gastrointestinal symptoms in the elderly: a population-based study. Gastroenterology. 1992;102(3):895–901.

    Article  CAS  Google Scholar 

  8. Sommers T, Mitsuhashi S, Singh P, Hirsch W, Katon J, Ballou S, et al. Prevalence of chronic constipation and chronic diarrhea in diabetic individuals in the United States. Am J Gastroenterol. 2019;114(1):135–42.

    Article  Google Scholar 

  9. Bayless TM, Brown E, Paige DM. Lactase non-persistence and lactose intolerance. Curr Gastroenterol Rep. 2017;19(5):23. https://doi.org/10.1007/s11894-017-0558-9.

    Article  PubMed  Google Scholar 

  10. Storhaug CL, Fosse SK, Fadnes LT. Country, regional, and global estimates for lactose malabsorption in adults: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2017;2(10):738–46.

    Article  Google Scholar 

  11. Buchman AL. Intestinal failure and rehabilitation. Gastroenterol Clin N Am. 2018;47(2):327–40.

    Article  Google Scholar 

  12. Philip NA, Ahmed N, Pitchumoni CS. Spectrum of drug-induced chronic diarrhea. J Clin Gastroenterol. 2017;51(2):111–7.

    Article  CAS  Google Scholar 

  13. Abraham BP, Sellin JH. Drug-induced, factitious, & idiopathic diarrhoea. Best Pract Res Clin Gastroenterol. 2012;26(5):633–48.

    Article  Google Scholar 

  14. • Pardi DS. Diagnosis and management of microscopic colitis. Am J Gastroenterol. 2017;112(1):78–85. Review of a common cause of chronic diarrhea in older patients.

    Article  Google Scholar 

  15. Gentile N, Yen EF. Prevalence, pathogenesis, diagnosis, and management of microscopic colitis. Gut Liver. 2018;12(3):227–35.

    Article  Google Scholar 

  16. Bergman D, Clements MS, Khalili H, Agréus L, Hultcrantz R, Ludvigsson JF. A nationwide cohort study of the incidence of microscopic colitis in Sweden. Aliment Pharmacol Ther. 2019;49(11):1395–400.

    Article  Google Scholar 

  17. Gentile NM, Khanna S, Loftus EV Jr, et al. The epidemiology of microscopic colitis in Olmsted County from 2002–2010: a population-based study. Clin Gastroenterol Hepatol. 2014;12(5):838–42.

    Article  Google Scholar 

  18. Holt PR. Intestinal malabsorption in the elderly. Dig Dis. 2007;25:144–50.

    Article  Google Scholar 

  19. Schiller LR. Diarrhea and malabsorption in the elderly. Gastroenterol Clin N Am. 2009;38(3):481–502.

    Article  Google Scholar 

  20. Marth T. Tropheryma whipplei, immunosuppression and Whipple’s disease: from a low-pathogenic, environmental infectious organism to a rare, multifaceted inflammatory complex. Dig Dis. 2015;33(2):190–9.

    Article  Google Scholar 

  21. Ahmed Z, Imdad A, Connelly JA, Acra S. Autoimmune enteropathy: an updated review with special focus on stem cell transplant therapy. Dig Dis Sci. 2018;64:643–54. https://doi.org/10.1007/s10620-018-5364-1.

    Article  PubMed  Google Scholar 

  22. Ebrahim VS, Martin J, Murthy S, Odstrcil E, Huang H, Polter D. Olmesartan-associated enteropathy. Proc (Baylor Univ Med Cent). 2017;30(3):348–50.

    Article  Google Scholar 

  23. Collin P, Vilppula A, Luostarinen L, Holmes GKT, Kaukinen K. Review article: coeliac disease in later life must not be missed. Aliment Pharmacol Ther. 2018;47(5):563–72.

    Article  CAS  Google Scholar 

  24. Sherid M, Samo S, Sulaiman S, et al. Comparison of ischemic colitis in the young and the elderly. WMJ. 2016;115(4):196–202.

    PubMed  Google Scholar 

  25. Löhr JM, Panic N, Vujasinovic M, Verbeke CS. The ageing pancreas: a systematic review of the evidence and analysis of the consequences. J Intern Med. 2018;283(5):446–60.

    Article  Google Scholar 

  26. Hirth M, Härtel N, Weiss C, Hardt P, Gubergrits N, Ebert MP, et al. Clinical course of chronic pancreatitis in elderly patients. Digestion. 2019;10:1–8. https://doi.org/10.1159/000494349.

    Article  Google Scholar 

  27. Quigley EMM. The spectrum of small intestinal bacterial overgrowth (SIBO). Curr Gastroenterol Rep. 2019;21(1):3. https://doi.org/10.1007/s11894-019-0671-z.69.

    Article  PubMed  Google Scholar 

  28. • Rezaie A, Pimentel M, Rao SS. How to test and treat small intestinal bacterial overgrowth: an evidence-based approach. Curr Gastroenterol Rep. 2016;18(2):8. https://doi.org/10.1007/s11894-015-0482-9. Review of the evaluation and management of SIBO in adults.

    Article  PubMed  Google Scholar 

  29. Mitsui T, Shimaoka K, Goto Y, Kagami H, Kinomoto H, Ito A, et al. Small bowel bacterial overgrowth is not seen in healthy adults but is in disabled older adults. Hepatogastroenterology. 2006;53(67):82–5.

    PubMed  Google Scholar 

  30. van Walree IC, van Tuyl SA, Hamaker ME. Late-onset inflammatory bowel disease in the very elderly. Neth J Med. 2015;73(1):4–9.

    PubMed  Google Scholar 

  31. Butter M, Weiler S, Biedermann L, Scharl M, Rogler G, Bischoff-Ferrari HA, et al. Clinical manifestations, pathophysiology, treatment and outcome of inflammatory bowel diseases in older people. Maturitas. 2018;110:71–8.

    Article  Google Scholar 

  32. John ES, Katz K, Saxena M, Chokhavatia S, Katz S. Management of inflammatory bowel disease in the elderly. Curr Treat Options Gastroenterol. 2016;14(3):285–304.

    Article  Google Scholar 

  33. White AE, Clampa N, Chen Y, et al. Characteristics of Campylobacter, Salmonella infections and acute gastroenteritis in older adults in Australia, Canada, and the United States. Clin Infect Dis. 2019. https://doi.org/10.1093/cid/ciy1142.

  34. Jump RLP, Crnich CJ, Mody L, Bradley SF, Nicolle LE, Yoshikawa TT. Infectious diseases in older adults of long-term care facilities: update on approach to diagnosis and management. J Am Geriatr Soc. 2018;66(4):789–803.

    Article  Google Scholar 

  35. Asempa TE, Nicolau DP. Clostridium difficile infection in the elderly: an update on management. Clin Interv Aging. 2017;12:1799–809.

    Article  CAS  Google Scholar 

  36. Donskey CJ. Clostridium difficile in older adults. Infect Dis Clin N Am. 2017;31(4):743–56.

    Article  Google Scholar 

  37. •• McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):987–94. https://doi.org/10.1093/cid/ciy149. Current consensus viewpoint on the management of C. difficile.

    Article  CAS  Google Scholar 

  38. Ooijevaar RE, van Beurden YH, Terveer EM, Goorhuis A, Bauer MP, Keller JJ, et al. Update of treatment algorithms for Clostridium difficile infection. Clin Microbiol Infect. 2018;24(5):452–62.

    Article  CAS  Google Scholar 

  39. •• Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, et al. Bowel disorders. Gastroenterology. 2016;150:1393–407. Rome IV definitions of functional bowel disorders, including IBS-D.

    Article  Google Scholar 

  40. Canavan C, West J, Card T. The epidemiology of irritable bowel syndrome. Clin Epidemiol. 2014;6:71–80.

    PubMed  PubMed Central  Google Scholar 

  41. Yu SW, Rao SS. Anorectal physiology and pathophysiology in the elderly. Clin Geriatr Med. 2014;30(1):95–106.

    Article  Google Scholar 

  42. Serrano Falcón B, Barceló López M, Mateos Muñoz B, Álvarez Sánchez A, Rey E. Fecal impaction: a systematic review of its medical complications. BMC Geriatr. 2016;16:4. https://doi.org/10.1186/s12877-015-0162-5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Borbély YM, Osterwalder A, Kröll D, et al. Diarrhea after bariatric procedures: diagnosis and therapy. World J Gastroenterol. 2017;23(26):4689–700.

    Article  Google Scholar 

  44. Schiller LR. Antidiarrheal drug therapy. Curr Gastroenterol Rep. 2017;19(5):18. https://doi.org/10.1007/s11894-017-0557-x.

    Article  PubMed  Google Scholar 

  45. Camilleri M. Bile acid diarrhea: prevalence, pathogenesis, and therapy. Gut Liver. 2015;9(3):332–9.

    Article  CAS  Google Scholar 

  46. Teo MTW, Sebag-Montefiore D, Donnellan CF. Prevention and management of radiation-induced late gastrointestinal toxicity. Clin Oncol. 2015;27:656–67.

    Article  CAS  Google Scholar 

  47. Zboromyrska Y, Vila J. Advanced PCR-based molecular diagnosis of gastrointestinal infections: challenges and opportunities. Expert Rev Mol Diagn. 2016;16(6):631–40.

    Article  CAS  Google Scholar 

  48. • Schumann D, Klose P, Lauche R, Dobos G, Langhorst J, Cramer H. Low fermentable, oligo-, di-, mono-saccharides and polyol diet in the treatment of irritable bowel syndrome: a systematic review and meta-analysis. Nutrition. 2018;45:24–31. Systematic review of the impact of the low FODMAPs diet in IBS.

    Article  CAS  Google Scholar 

  49. • Vijayvargiya P, Camilleri M. Update on bile acid malabsorption: finally ready for prime time? Curr Gastroenterol Rep. 2018;20(3):10. https://doi.org/10.1007/s11894-018-0615-z. This review focuses on bile acid malabsorption as a common mechanism of chronic diarrhea.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX, 75246, USA

    Lawrence R. Schiller

  2. Texas A&M College of Medicine, Dallas Campus, Dallas, TX, USA

    Lawrence R. Schiller

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Lawrence Schiller reports personal fees from Allergan, Ardelyx, Ironwood, Salix/Bausch, Shire, Commonwealth Laboratories, Prometheus Laboratories, Abbvie and Romark, outside the submitted work.

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Schiller, L.R. Chronic Diarrhea Evaluation in the Elderly: IBS or Something Else?. Curr Gastroenterol Rep 21, 45 (2019). https://doi.org/10.1007/s11894-019-0714-5

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